◇There is no conflict of interest to disclose with regard to this subject.

◇I asked my co-author, Dr. Li of the National Taiwan University, to make some
improvements to his idea ultrasound biomicroscope (UBM), for uses in obstetric
and gynecological diagnosis. Said improvements were carried out entirely at my
own expense.

◇And after twenty years’ work, I am at long last able to make an announcement
to you all today regarding the Sterility Tomography Komputer Ultrasound
Biomicroscope (ST-TOMKO UBM) system for imaging oocyte cumulus cell
complexes (OCC) in human ovarian follicles.

◇ In English, an OCC is apparently generally called a COC. But the usual Japanese word for a COC translates to “oocyte cumulus cell complex”, so to emphasize the fact that this is a product originally developed in Japan, I have chosen to use the term OCC instead of COC.

◇I would like to express my deep gratitude to the IFFS and JSRM for accepting
my “First Report” for an “Others” session of this world congress.

◇ I apologize that the content of this presentation is slightly different from that of the abstract.

◇ I’m afraid I’m not very good at English. If anything in my presentation was difficult to understand, I would like to talk more in the discussion room through an interpreter.

◇ This presentation is represents about 10% of everything I want to talk about. Therefore, I can't tell you all the details about the development. If you would like to know more, I will make a further presentation at another time and place.

Slide 2.

Follicle image using 5 MHz Sonivista Ex

This image shows a 20 x 18 mm follicle, this was examined in about 20 years ago using a conventional ultrasound reflectoscope of the time (called Sonovista EX).
I can see an echo high body on the opposite side of this follicle to the probe head.
I wondered about it for 20 years.

After a great deal of research, I successfully invented a new ultrasound device for diagnosing OCCs in follicle using a UBM.
I obtained a patent for an egg observation device on January 6th, 2006.
It was called ST-TOMKO UBM, from “STerility-TOMography KOmputer UBM”.

Slide 4.

In January 2014, my plan received a further boost when Dr. Pai-Chi Li, a distinguished professor at National Taiwan University, became a joint developer of ST-TOMKO UBM.
This slide shows his UBM.

Slide 5.

Image using Prospect 40MHz about Cumulus cells
in balloon

This image is of cumulus cells which were actually removed from an ovary at oocyte pick up, and was made using Dr. Li’s UBM .
On the left is an optical microscope picture of a cumulus cells, and on the right is a scanned image made using UBM .
It is being said that the OCC image is similar to that from an optical microscope.
Ultrasound frequency is 40MHz, and the diameter of the cumulus cells is about 700 μm.

Slide 6.

Ethics committee

In order to carry out clinical trials for actual imaging of human OCCs in follicles,
I consulted Dr. Naohisa Ishikawa, chairman of the NPO the Aichi Clinical Trials Ethics Committee and former President of Aichi Medical University, and held a Fujisawa Frauen Klinik Ethics Committee with Dr. Ishikawa, with members of Fujisawa Frauen Klinik’s ethics committee also present.
As a result of these consultations, a project plan for clinical trials for the imaging of OCCs in human ovarian follicles using ST-TOMKO UBM was created.

Slide 7.

Project plan for clinical trial

This is the project plan for clinical trials which was decided through the Ethics Committee.

Slide 8.

Targets for clinical trials

The targets for the clinical trials are followings.
1. Premature ovarian insufficiency patients: AMH<1.0 ng/ml, FSH>10 mIU/ml, AFC<3 (menstral cycle D5).
2. Patients in whom fewer than two follicles develop even under superovulation.
3. Patients who have not been able to have a baby after undergoing IVF treatment several times.
4. Patients who have been diagnosed with so-called Empty Follicle Syndrome through IVF treatment.

I began clinical trials after obtaining patients’ informed consent with regard to the content of the project plan for clinical trials related to the benefits of the ST-TOMKO UBM , and improvement of same.

Slide 9.

ST-TOMKO UBM Prototype 1

This is ST-TOMKO UBM Prototype 1, my first diagnostic device for OCCs in human follicles

Slide 10.

ST-TOMKO UBM Prototype 1 probe

This is ST-TOMKO UBM Prototype 1’s probe, which Dr. Li developed by modifying a his UBM probe so that it could have a diameter of less than 3 cm and would therefore be suitable for gynecological specifications.

Slide 11.

ST-TOMKO UBM System specification

This is the System Specification.

As indicated here, ST-TOMKO UBM’s Mechanical Index is 0.28 at 20MHz and 0.18 at 40MHz, and the Thermal Index is under 0.5.
Both indices meet the safety standards of the FDA, the American Institute of Ultrasound in Medicine (AIUM), and the Electronic Industries Alliance.
Similar UBMs are already being used as medical instruments in ophthalmology, and in veterinary reproductive medicine for mammals (especially bovines).

Slide 12.

An Animation showing an early antral follicle without OCC scanned by ST-TOMKO UBM.
Follicle size is 1.5mm×1.5mm

This animation was made by scanning inside an early antral follicle measuring about1.5×1.5 mm using ST-TOMKO UBM.
I was unable to identify an OCC-like object in this follicle.

Slide 13.

An animation of an early antral follicle and OCC
scanned by ST-TOMKO UBM
Follicle size is 2mm×2 mm

This is an animation of a follicle measuring about 2×2 mm the early antral follicle.
Some light shading can be seen under the follicle.

This animation repeats the same few seconds’ worth of frames over and over.
This is because even if the probe is being held steady, just the movement from the patient’s breathing is enough to make an object that might be an OCC disappear from the screen.

It is important to be aware of how difficult it is to capture such a small object manually.

The method of identifying an OCC during a scan is to search every nook and cranny of the follicle wall slowly and thoroughly.
Other than an OCC, there can be no object with an echo low center of about 80 to 100 μm surrounded by echo high . It is therefore important to operate the probe more slowly after such an object has been found.

Slide 14.

Enlarged image of OCC in an early antral follicle
OCC diameter is around 135 μm
Follicle size is 2mm×2mm

This is an enlarged static image from the previous animation.
In a follicle , it is possible to identify an approximately 80-μm-diameter oocyte,
and around it an echo high object thought to be a corona radiate.
It seem to be OCC is about 135μmΦ.

This patient grew another two Graafian follicles in another location.
So, I had to perform oocyte collection very quickly.
I tried using a 22-gage needle to collect oocytes from this early antral follicle.
But I was unable to collect oocytes from such a small antral follicle.
The reason for this was that granulosa cells and cumulus cells in a follicle under 5 mm in diameter do not have a receptor for LH.
Consequently the OCC cannot expand, and cannot pare off from inside the follicle wall. So, I could not retrieve the OCC from this follicle.

Slide 15.

An animation of OCC in a latter period antral follicle scanned by ST-TOMKO UBM
Follicle size is 15mmΦ

This animation was made by scanning inside a latter period antral follicle using ST-TOMKO UBM.
Fortunately, there was a 15-mm-diameter OCC on the side of the follicle nearest to the probe head, so an OCC-like image could be obtained.

For the animation, the scan was made at a position about 5 to 10 mm from the probe head.

For me, this animation is a memento of the first scan I performed from outside the body of a patient.

Slide 16.

Enlarged static image of a latter period OCC in follicle scanned by ST-TOMKO UBM
OCC size is 200mmΦ

This is an enlarged view.
From the size,it is thought to be an oocyte of diameter about 100μm.
Around the oocyte we can see an object like a corona radiate, picked up as echo high.
The total size is about 200μm in diameter.
So, this is thought to be an OCC before undergoing expansion.

Slide 17.

Optical microscope image of OCC from scanned follicle

This is an optical microscope picture of an OCC which was actually retrieved from the follicle in the previous scan.
In this picture, the cumulus cells are about 400μm in diameter.
However, in the ST-TOMKO UBM image, it was not possible to detect cumulus cells which had yet to undergo expansion.

I will be able to get better images by increasing the number of cases studied, bringing the probe head closer to the follicles, adjusting the UBM frequency, out-put and gain and so on.

Slide 18.

Animation of cortex and medulla of ovary scanned by ST-TOMKO UBM

This animation is a scanned image of an ovary surface.
We can distinguish the cortex and medulla of the ovary.

Slide 19.

Smallest antral follicle in ovary scanned by ST-TOMKO UBM

This animation shows the smallest early antral follicle in the cortex of the ovary, witch I can detect within 1 mm of the surface.

Slide 20.

Smallest antral follicle
Follicle size is 200μmΦ

This early antral follicle is 200μm in diameter.

Slide 21.

Conclusion

◇This clinical trial for imaging of OCCs using ST-TOMKO UBM was
started for the purpose of investigating female fertility non-invasively.

◇ I was able to detect OCCs in follicles of 2 to 3 mm in diameter in this clinical trial.
So, I am of the opinion that Empty Follicle Syndrome can be detected by frequent scanning during the early antral follicle stage.

◇ With this prototype, thorough diagnosis can be made of the inside of follicles which are up to about 6 mm in diameter.

◇“Who is first in the world” or “Who planned it first” are not important
at all.

◇If there is anyone out there who has thought of this kind of project
before me I would be delighted to meet them.

◇I cannot complete this project working alone.

◇We need to adopt a global point of view when it comes to clinical trials
in reproductive medicine, particularly concerning oocytes.

◇Oocytes are fundamental to pregnancy, and there can be no doubt
that assessing oocyte quality and retrieving good oocytes will
contribute to future progress in reproductive medicine.

◇So it is my hope that everyone involved in reproductive medicine here
today will be able to participate this project and create new
diagnostic criteria.

◇I would be extremely happy if my presentation can contribute to that.

◇At last, I would like to express my deepest gratitude to Dr. Pai-Chi Li
of the National Taiwan University to improve my first equipment as
ST-TOMKO UBM for diagnose OCC in the human ovarian follicle